Many adults are survivors of childhood physical or sexual abuse. In the first and perhaps the most rigorous prevalence study on childhood sexual abuse ever done, Diana Russell found that 38% of adult females in the San Francisco area had experienced contact sexual abuse as a child. Although the commission of sexual abuse appears to be decreasing, it is likely that approximately 30% of girls and 15% of boys are victimized. Prevalence studies of childhood physical abuse also suggest that 20% to 30% of individuals experience physical abuse in childhood. Although some children experience few effects of the abuse, most experience effects that undermine their functioning in at least one domain. For those who do not receive treatment or do not have other reparative experiences in childhood, these effects may be long term. For some, effects will be debilitating.
Types of Effects of Childhood Abuse
Perhaps the most wounded survivors of childhood abuse are found on the fringes of life, in jails or on the streets—prostitutes, drug addicts, and chronically mentally ill individuals. Survivors of childhood abuse are more likely than those not experiencing abuse to experience a wide array of problems, including physical health problems and committing acts of harm against themselves. Survivors are more likely than their nonabused counterparts to repeat a grade in school and are less likely to graduate. They also have consensual sex earlier; have more sexual relationships, sexual problems, and teenage pregnancy; and divorce more often. Survivors are at greater risk than those not abused for substance abuse, suicide attempts, committing violent acts, prostitution, adult victimization, criminality, being abusive to a child as an adult, and homelessness. Further, survivors of childhood abuse are overrepresented in health systems and are grossly overrepresented in mental health systems, as most inpatients and outpatients in mental health hospitals or agencies have a history of childhood maltreatment. Those survivors of childhood abuse with the most difficult adult trajectories may be those coming through the foster care system, as they are often poorly equipped with resources to transition safely into adulthood. The institutionalization, medical and mental health care, substance use, sexually transmitted diseases, and other problems associated with childhood abuse are a burden for society and cost billions of dollars each year.
The Brain’s Response to Abuse and Terror
To understand why the effects of the abuse can be so extreme, one must have some understanding of how the brain responds to the experience of abuse. Most importantly, abuse in young children organizes the brain around the experience of the abuse. Development of the brain is dependent upon the environment. Thus the brain is taught, via the child’s interaction with caregivers and the environment, how to respond to that environment. If the child experiences the environment as intermittently or chronically terrifying, the child responds in a state of heightened arousal or terror. Over time the child experiences the state of heightened arousal or terror even in nonabusive situations. The child becomes sensitized to the reaction, moving into it more and more easily. This heightened responsivity then becomes generalized to nonabusive events. The response induced by the trauma also leads to a chemical response associated with the hypothalamic-pituitary-adrenal axis that involves an increase of cortisol in the body. This chemical is critical for preparing the body to respond to the crisis. This stress response, associated with the release of cortisol, is thought to be related to some of the mental and health problems seen in many survivors of abuse.
Combined, two primary responses are prevalent in relation to trauma—a response related to a heightened anxiety related to the trauma, and a response of dissociation from the trauma. The first response is associated with increased blood pressure and heart rate, among other physiological indicators of heightened bodily responses that allow the individual to fight or flee. These features are represented sympto-matically in adults primarily by heightened anxiety and associated disorders. The dissociative response, in contrast, is associated with decreased heart rate and blood pressure, among other physiological indicators representing a freeze response. These features are represented symptomatically in adults primarily by the dissociative disorders. The other obvious diagnostic category related to abuse is posttraumatic stress disorder. This disorder is represented by three groups of symptoms—hyperarousal and avoidant and intrusive symptoms. This disorder is closely associated with the same changes in the brain as discussed previously.
Treatment
Treatment for adult survivors of abuse typically consists of three phases. The first stage is a period of stabilization. This stage is particularly important for individuals who experience symptoms such as suicidality, self-injurious behaviors, or other destabilizing behaviors. During this phase of treatment it is also important for survivors struggling with relationships, those who are parenting, and any survivors experiencing heightened stress when entering treatment, to achieve stability in their lives. It is also a phase in which survivors are encouraged to create or strengthen support networks. The purpose of the first phase is to provide survivors with techniques they can use to control and manage their symptoms, as well as with coping skills and other necessary efforts to regain stability in their lives.
During the second phase, survivors process their experiences of abuse and the environments in which the abuse occurred. Multiple formal or informal techniques can be used to help survivors process the abuse events for the purpose of integrating the emotional and cognitive knowledge of the experience. It is not unusual for survivors to isolate memories of abuse from their everyday lives for fear that the memories will overwhelm them. During this phase, survivors often explore the experience of the abuse, its meaning to them when they were young, its effect on them then and now, and how it changed them. The purpose of this second phase is to reconcile the experience of abuse so that it no longer overwhelms individual functioning.
The final phase of treatment is one of integration of the abuse context with the survivor’s current life. Survivors come to a better understanding of what happened to them in the past and recognize the decisions they can make about themselves today and in the future. The purpose of this phase is to help clients understand the abuse as a part of their history—often a significant part of their history—while living in the here and now with either partial or complete relief of symptoms. Even in the early 1990s, it was thought that with enough treatment, all survivors could overcome the effects of the abuse. With the developing knowledge of the effects of abuse on the brain, however, it is now being recognized that some of the effects of the abuse on the brain, such as the heightened stress response and emotional dysregulation, may lessen but may not be extinguished. Thus, some survivors in this phase may also work toward management of those symptoms that remain.
The effects of abuse on survivors can be overwhelming. The abuse can deprive them of relationships, mental health, careers, or even their lives. The abuse also deprives society of the enormous lost potential of the lives of those affected and costs society billions of dollars a year. And the damage from the abuse to the brain is just beginning to be understood. Yet what is known even at this early stage is that the damage that occurs to the brain is potentially calamitous. Thus the abuse may potentially change forever and irrevocably the life patterns of survivors, their career paths, their successes, and their potential for what they can achieve.
